PLACENTAL ABRUPTION premature separation of the normally implanted placenta
Etiology RISK FACTORS RELATIVE RISK Increased age and parity 1.31.5 Preeclampsia 2.14.0 Chronic hypertension 1.83.0 Preterm ruptured membranes 2.44.9 Preterm ruptured membranes 2.1 Hydramnios 2.0 Cigarette smoking 1.41.9 Thrombophilias 37 Cocaine use NA Prior abruption 1025 Uterine leiomyoma NA
Pathology Initiated by hemorrhage into the decidua basalis. In its earliest stages consists of the development of a decidual hematoma that leads to separation, compression, and the ultimate destruction of the placenta adjacent to it In some instances, a decidual spiral artery ruptures to cause a retroplacental hematoma, which as it expands disrupts more vessels to separate more placenta
CONCEALED HEMORRHAGE Retained or concealed hemorrhage is likely when: There is an effusion of blood behind the placenta but its margins still remain adherent. The placenta is completely separated yet the membranes retain their attachment to the uterine wall. Blood gains access to the amnionic cavity after breaking through the membranes. The fetal head is so closely applied to the lower uterine segment that the blood cannot make its way past it.
Signs and Symptoms Determined Prospectively in 59 Women with Abruptio Placentae Sign or Symptom Frequency (%) Uterine tenderness or back pain 78 66 Fetal distress 60 Preterm labor 22 High-frequency contractions 17 Hypertonus 17 Dead fetus 15
Differential Diagnosis Vaginal bleeding complicating a viable pregnancy, it often becomes necessary to rule out placenta previa and other causes of bleeding by clinical inspection and ultrasound evaluation. Painful uterine bleeding means placental abruption, whereas painless uterine bleeding is indicative of placenta previa. Labor accompanying placenta previa may cause pain suggestive of placental abruption. Abruption may mimic normal labor, or it may cause no pain at all. The latter is more likely with a posteriorly implanted placenta
CONSUMPTIVE COAGULOPATHY One of the most common causes of clinically significant consumptive coagulopathy in obstetrics is placental abruption Overt hypofibrinogenemia (less than 150 mg/dL of plasma) along with elevated levels of fibrinogenfibrin degradation products, D-dimers, and variable decreases in other coagulation factors are found in about 30 percent of women with placental abruption severe enough to kill the fetus activation of plasminogen to plasmin, which lyses fibrin microemboli, thereby maintaining patency of the microcirculation
RENAL FAILURE seen in severe forms of placental abruption, includes those in which treatment of hypovolemia is delayed or incomplete Seriously impaired renal perfusion is the consequence of massive hemorrhage. vigorous treatment of hemorrhage with blood and crystalloid solution often prevents clinically significant renal dysfunction
COUVELAIRE UTERUS (UTEROPLACENTAL APOPLEXY) Widespread extravasation of blood into the uterine musculature and beneath the uterine serosa occasionally seen beneath the tubal serosa, in the connective tissue of the broad ligaments, and in the substance of the ovaries, as well as free in the peritoneal cavity seldom interfere with uterine contractions sufficiently to produce severe postpartum hemorrhage Not an indication for hysterectomy.
PLACENTA PREVIA In placenta previa, the placenta is located over or very near the internal os. Four degrees of this abnormality have been recognized. Total placenta previa The internal cervical os is covered completely by placenta Partial placenta previa The internal os is partially covered by placenta Marginal placenta previa The edge of the placenta is at the margin of the internal os. Low-lying placenta The placenta is implanted in the lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it. Vasa previa The fetal vessels course through membranes and present at the cervical os
Factors associated with Placenta Previa: Advancing maternal age At the extremes, it is 1 in 1500 for women 19 years of age or younger, and it is 1 in 100 for women older than 35 years of age.
Multiparity 40 percent higher in multifetal gestations compared with that of singletons. Previous pregnancies permanenetly damage the endometriu underlying the placental site making suitable for the placenta in subsequent pregnancies Prior cesarean delivery A prior uterine incision with a previa increases the incidence of cesarean hysterectomy. Defective vascularization of the deciduas as a result of inflammatory or atrophic changes Smoking Relative risk of placenta previa to be increased twofold Carbon monoxide hypoxemia caused compensatory placental hypertrophy
Diagnosis Placenta previa or abruption should always be suspected in women with uterine bleeding during the latter half of pregnancy. seldom be established firmly by clinical examination unless a finger is passed through the cervix and the placenta is palpated. Such examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean delivery, because even the gentlest examination of this sort can cause torrential hemorrhage safest method of placental localization is provided by transabdominal sonography Magnetic Resonance Imaging
PLACENTAL MIGRATION mechanism of apparent placental movement. The term migration is clearly a misnomer, however, because invasion of chorionic villi into the decidua on either side of the cervical os persists. This difficulty is coupled with differential growth of lower and upper myometrial segments as pregnancy progresses. Thus, those placentas that "migrate" most likely never had actual circumferential villus invasion that reached the internal cervical os in the first place.
PATHOLOGIC OB: Page | 3 DULIG, Argent Aebi DP Management Women with a placenta previa may be considered as follows: Those in whom the fetus is preterm and there is no indication for delivery. Target date: 37 weeks Hospitalization, replace blood loss, keep crossmatched blood available, bed rest under close observation May go home provided that patient lives within 20-30 minutes from the hospital Those in whom the fetus is reasonably mature. Delivery by Cesarean section Those in labor. General rule: method of delivery of choice in patients with degree of placenta previa is Ceasarean section EXCEPT in cases of marginal or low lying placenta implanted anteriorly with advanced cervical dilatation and head is engaged Those in whom hemorrhage is so severe as to mandate delivery despite fetal immaturity.
ABRUPTIO PLACENTA PLACENTA PREVIA History Frequent association of pre- eclampsia or hypetension from any cause A single attack of vaginal bleeding which usually continues until delivery Abdominal pain No association with pre-eclampsia Repeated warning hemorrhages often occurring over a period of weeks No abdominal pain Abdominal examination Local uterine tenderness, hypertonic uterus in a concealed abruption Patients usually in labor Presenting part not engaged Fetal parts maybe difficult to palpate FHT often absent Normal uterine tone and usually no tenderness Patient rarely in labor Presenting part above brim, malpresentation frequently found Fetal parts usually palpable FHT present Ancillary Aids Placenta demonstrated in the upper uterine segment Placenta demonstrated in the lower uterine segment Vaginal examination NO placenta within 5 cm of the cervical os Placenta implanted in the Lower uterine segment Management No place in expectant management < 36 week, bleeding stopped, expectant management is indicated